Endometriosis affects fertility. This is because it is associated with chronic inflammation, pelvic adhesions and a reduced ovarian reserve.

Women with mild endometriosis can achieve a natural pregnancy, but moderate–severe cases benefit from personalised IVF. Pregnancy, once it occurs naturally or through IVF, is the best treatment for endometriosis. After a first pregnancy, for example obtained through IVF, the second may occur naturally. This is because pregnancy hormones act as a treatment for endometriosis.

Endometriosis typically develops a few years after the onset of menstruation. Signs and symptoms may improve once a pregnancy occurs and disappear at menopause, except in situations where you are on hormone replacement therapy (oestrogens).

What is endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the uterine cavity (the endometrium) develops outside the uterus. The endometrium is the tissue that is shed during menstruation if pregnancy does not occur.

The endometrium is the tissue inside the uterus where the embryo implants (attaches) once it appears in the fallopian tubes following natural fertilisation.

Once it develops, endometriosis often involves the ovaries, fallopian tubes and peritoneum (the membrane lining the pelvic cavity).

Endometriotic tissue can also extend beyond the pelvic area and affect neighbouring organs. Endometriosis can be found in the urinary tract and in the intestines. In fact, histological (laboratory) analyses have shown that it can appear on almost all organs in the body.

Stages of endometriosis

Endometriosis is generally classified into four stages (1 – mild, 2 – moderate, 3 – advanced, 4 – severe), depending on the number, size and location of the lesions and adhesions.

• Peritoneal endometriosis – Superficial lesions on the pelvic peritoneum.
• Ovarian endometriosis – Endometriotic cysts (“chocolate cysts”) on the ovaries.
• Deep infiltrating endometriosis – Lesions that invade deeply into pelvic organs (uterosacral ligaments, rectovaginal septum, bladder, intestine).

The stage of endometriosis does not always correlate directly with the intensity of the pain, but it is important for planning treatment and for counselling about fertility.

Endometriosis of the uterine wall (adenomyosis)

This is called adenomyosis and means the presence of endometriotic tissue within the uterine wall. Symptoms of adenomyosis include heavy menstrual bleeding and severe pain.

Endometriosis of the ovaries

When endometriosis affects the ovaries, cysts form called endometriomas. Endometriomas contain brown fluid.

Adhesions

Adhesions are a frequent consequence of endometriosis. These are bands of fibrous tissue that form between the walls of the pelvic cavity and the pelvic organs or other neighbouring organs.

Why does endometriosis occur?

The exact cause of endometriosis is not known. Worldwide, several theories have been proposed to explain the causes of the disease:

Retrograde menstruation

Menstrual blood, which contains endometrial cells (from the endometrium) and should normally be eliminated from the body as menstrual flow, passes through the fallopian tubes into the pelvic cavity. These cells adhere to the pelvic walls and to the surface of organs, where they divide and form endometriotic foci that thicken and bleed at every menstruation.

Mulleriosis theory

This theory suggests a developmental defect during organ formation, specifically involving the migration of cellular components from the Müllerian ducts. These ducts are the structures from which the reproductive organs develop. Müllerian tissues can migrate within the body in the embryonic phase and later develop under the influence of hormones.

Genetic causes

There may be a genetic predisposition to endometriosis in some women.

Symptoms of endometriosis

The main symptom is pain. Endometriosis is among the 20 most painful diseases. The pain is not necessarily related to the stage of the disease.

A woman with early-stage endometriosis may experience severe pain, while another with advanced-stage endometriosis may have minimal symptoms.

Pelvic pain can also occur outside menstruation and become constant.

Common symptoms of endometriosis (endometriosis symptoms)

• pain during menstruation (dysmenorrhoea): pelvic pain and cramps may begin before menstruation and last for a longer period
• pain during sexual intercourse (dyspareunia): pain during or after sex is common in endometriosis
• pain when urinating or during bowel movements (intestinal peristalsis): these symptoms may occur during menstruation
• infertility: endometriosis is often diagnosed in women who are unable to achieve a pregnancy
• digestive discomfort: bloating, alternating constipation/diarrhoea, nausea
• back pain
• pain radiating down the leg

Diagnosis of endometriosis (endometriosis diagnosis)

PTo diagnose endometriosis and differentiate it from other causes of pelvic pain, the gynaecologist will take a detailed medical history.

In addition, you will undergo the following investigations, as recommended by your gynaecologist:

• Pelvic clinical examination: the doctor will palpate the entire pelvic area to detect signs of endometriosis, such as cystic formations or adhesions.
• Ultrasound examination: transvaginal ultrasound allows visualisation of the internal reproductive organs and can also identify the presence of adhesions.
• MRI (magnetic resonance imaging): for diagnosing endometriosis, an MRI with an endometriosis protocol is recommended, which involves the instillation of rectal and vaginal gel. MRI is very important for planning surgery.

Laparoscopy for endometriosis (endometriosis laparoscopy) is a surgical procedure performed under general anaesthesia that allows direct visualisation of the intra-abdominal organs. The doctor makes small incisions in the abdominal wall and introduces a video camera and surgical instruments to look for areas of endometriosis outside the uterus. Laparoscopy provides information about the location, extent and size of endometriotic implants.ne de endometrioză în afara uterului. Laparoscopia oferă informații despre localizarea, extinderea și mărimea implantelor endometriozice.

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Treatment of endometriosis (endometriosis treatment)

Treatment of endometriosis involves medication or surgery. The treatment approach depends on the severity of the disease and symptoms, the patient’s age and whether or not she wishes to become pregnant.

Initially, doctors opt for conservative treatment and, later, surgical treatment may be required.

Conservative treatment for endometriosis

Pain medication

The doctor will recommend non-steroidal anti-inflammatory drugs to reduce menstrual pain. If the patient does not wish to become pregnant, oral contraceptives can be given in combination with pain medication.

Hormone therapy

Hormonal treatment is not curative in endometriosis; it is symptomatic. The only form of the disease that can be controlled with hormone therapy is ovarian endometriosis. In deep endometriosis, hormonal treatment cannot stop or slow the progression of the disease.

Hormonal treatments used in endometriosis include:

• Oral contraceptives: they are effective for ovarian endometriosis and adenomyosis. Endometriomas can be kept under control with hormone therapy, and the symptoms of adenomyosis are improved.
• Gonadotropin-releasing hormone (GnRH) agonists and antagonists: these medications block the production of ovarian-stimulating hormones, lowering oestrogen levels and preventing menstruation. This leads to thinning of the endometrial tissue and induces a temporary, artificial menopause. Menstruation and the ability to become pregnant usually return after stopping the medication.
• Progesterone therapy: there are various progesterone-based therapies, including an intrauterine device (IUD), which can stop menstruation. This can help alleviate the symptoms of endometriosis.
• Aromatase inhibitors: a class of drugs that reduce the amount of oestrogen in the body. The doctor will recommend this treatment in combination with low-dose progesterone or oral contraceptives as part of endometriosis management.

Surgical treatment for endometriosis

Patients with endometriosis who wish to have a child benefit from removal of endometrial cysts while preserving the uterus and ovaries. Surgery also brings major benefit when the pain caused by endometriosis is severe.

The intervention is performed laparoscopically.

At Genesis Athens, laparoscopic surgery is carried out with microscopic precision by specialists with ESHRE certification.

Treatment of infertility

A doctor specialised in infertility treatment may recommend IVF if you have endometriosis and cannot achieve a pregnancy. Between 30% and 50% of women with endometriosis have difficulty conceiving.

Infertility is a frequent complication of endometriosis.

The relationship between endometriosis and infertility (endometriosis infertility)

Why does pregnancy not occur if you have endometriosis?

For pregnancy to occur, an egg is released from the ovary, travels through the fallopian tube and is fertilised there by a sperm cell. The resulting embryo then moves from the tube into the uterus and attaches to the uterine lining (endometrium), where it begins to develop.

• Endometriosis can affect the fallopian tubes, thereby preventing fertilisation.
• Endometriosis also affects fertility indirectly, for example through inflammation. Inflammation can affect egg quality and damage sperm cells. Inflammatory substances create an unfavourable environment for fertilisation and implantation of the fertilised egg.

Even early forms of the disease can cause infertility.

Fertility improves substantially when endometriotic lesions are surgically excised.

Can I get pregnant if I have endometriosis?

Yes. Although endometriosis is a major cause of infertility, many women still manage to achieve a natural pregnancy.

Pregnancy can also occur after conservative surgery (which excises the lesions and restores normal pelvic anatomy).

Pregnancy can also occur through assisted reproductive techniques such as in vitro fertilisation (IVF).

If you have endometriosis and want a child, a doctor specialised in infertility treatment will guide and coordinate your care.

Can I have a second pregnancy?

After you have had one pregnancy, even if you have endometriosis, a second pregnancy usually occurs more easily. This is because pregnancy hormones have a therapeutic effect on endometriosis. If you needed IVF for your first pregnancy, you may be able to conceive naturally the second time.

Frequently Asked Questions

What is endometriosis and why does it occur?
Endometriosis is a condition in which tissue similar to the lining of the uterine cavity (the endometrium) develops outside the uterus. The endometrium is the tissue that is shed during menstruation if pregnancy does not occur. It is also the tissue in which the embryo implants (attaches) once it appears in the fallopian tubes following natural fertilisation.

How do I know if I have endometriosis?
Pain is the main symptom – between periods, during sexual intercourse. Endometriotic foci can often be seen on ultrasound.

Can it be cured completely?
Endometriosis can be improved and controlled. It usually disappears at menopause. Endometriosis is an oestrogen-dependent disease; symptoms improve significantly and the disease generally goes into remission when menopause occurs (whether naturally or surgically induced by removal of the ovaries). Oestrogen levels fall and the lesions are no longer stimulated.

One exception is women who undergo oestrogen-based hormone replacement therapy after menopause, in which case symptoms may persist or recur.

What treatment is available for pelvic pain?
There are multiple medical and surgical treatment options.

Can I get pregnant with endometriosis?
Yes, it is possible.

Is endometriosis inherited genetically?
There can also be genetic causes.

How is “hidden” endometriosis detected?
MRI with an endometriosis protocol is recommended.

Can it recur after surgery?
Yes, it can recur after surgery. The recurrence rate depends on the stage of the disease, how complete the surgery was and whether postoperative hormonal treatment is used, when indicated.

Why choose Genesis Athens for the treatment of endometriosis

Genesis Athens is a reference centre for the diagnosis and treatment of endometriosis, with a medical team specialised in advanced laparoscopic surgery, reproductive medicine and pain therapy. Patients benefit from comprehensive evaluation, from the gynaecological consultation and imaging investigations through to the medical treatment plan, surgery and pain management.

The integrated fertility laboratory allows optimal management of patients with infertility associated with endometriosis, including through personalised IVF and ICSI. The approach is multidisciplinary, combining expertise in gynaecology, nutrition and psychology, so that each woman receives a care plan tailored to her needs. By choosing Genesis Athens, patients with endometriosis gain access to modern technology, extensive experience, and a team dedicated to improving their quality of life and their chances of achieving a pregnancy.

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